Healthcare Provider Details

I. General information

NPI: 1174638480
Provider Name (Legal Business Name): BRUCE GLICK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 MILL ST
HOULTON ME
04730-1877
US

IV. Provider business mailing address

43 HATCH DR PO BOX 1018
CARIBOU ME
04736-2161
US

V. Phone/Fax

Practice location:
  • Phone: 207-532-6523
  • Fax: 207-532-1877
Mailing address:
  • Phone: 207-498-6431
  • Fax: 207-492-3181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number351
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: